adenocarcinoma can only be achieved by histopathology, and an excisional biopsy including the endocervical canal is required for this purpose [2]. The excisional treatment needs to include the entire transformation zone and extend at least 1cm above the squamocolumnar junction [2], although this may increase the risk of preterm birth. All glandular cytology and histology samples should be discussed at the local colposcopy MDT meeting.
Those with complete excision should be offered HPV test of cure sampling 6‐ and 18‐months posttreatment and return to normal recall if both samples are normal [2]. In health systems without HPV test of cure, cytological follow up at 6 months and then annually for 10 years should be followed.
Those that are incomplete should consider a repeat LLETZ, accepting a further increased risk of preterm birth, or colposcopy and screening 6 months after treatment, and then annually for 10 years [2], whilst accepting that incomplete removal further increases the risk of recurrence of cervical disease which could lead to cancer in the future.
Key points
Challenge: abnormal cervical screening test in women undergoing infertility investigations or treatment.
Background:
Approximately 4% of women will have abnormal cervical screening, with the peak age group coinciding with the peak age group of infertility patients.
Untreated cervical abnormalities can progress to cancer for some, but can regress naturally for others.
Cervical treatment, particularly at depths greater than 10mm increase the preterm birth rate.
Those with abnormal cervical screening even without treatment have a higher preterm birth rate compared to those with normal screening histories.
Management options:
If minor cytologic abnormality is being managed by repeat cervical sample, then proceed with fertility treatment.
If low‐grade changes, then continue cytologic/colposcopic surveillance, but proceed with fertility treatment.
If high‐grade changes, then treat. Ideally, wait for reversion to normal with cervical sample +/− colposcopy. In exceptional circumstances, proceed with fertility management early following local treatment.
Prevention:
Encourage uptake of HPV vaccination.
Encourage women to take up the offer of HPV screening.
Encourage all women that smoke to stop.
Answers to questions patients ask
1 Q1 Why should I have a smear test? I am worried that the test results may delay my IVF treatment.A1. The cervical smear test is done to discover if there are any abnormalities in the cells covering the cervix. Some of these abnormalities, if not treated, may progress to cancer over time. So, the smear test reduces the chances of patients developing cervical cancer and saves lives. Also, it is better to be reassured before you start your IVF treatment and hopefully get pregnant. If any abnormality is discovered, then it is definitely much easier to sort out before pregnancy.
2 Q2 I had the vaccine. Doesn’t that mean that I will never get cervical cancer or HPV?A2. The vaccine covers the two most common oncogenic (cancer causing) strains of HPV which are HPV 16 and 18. These account for approximately 70% of cancers. However, there are many more strains out there which the vaccine does not cover.
3 Q3 What if I have cancer?A3. Most patients referred with an abnormal smear do not have cancer. The very small number that do tend to have early stage disease. The only way to know is to get tested. If there is a cancer, this can sometimes be treated with simple excisional treatments like a LLETZ under local anesthesia. Many patients with an early stage 1 cancer go on to have children afterwards.
References
1 1 https://www.gov.uk/guidance/cervical‐screening‐programme‐overview
3 3 Wuntakal R, Castanon A, Landy R, Sasieni P. How many preterm births in England are due to excision of the cervical transformation zone? Nested case control study. BMC Pregnancy Childbirth. 2015; 15:232. Published 2015 Sep 29. doi:10.1186/s12884‐015‐0664‐3
4 4 Kyrgiou M, Athanasiou A, Kalliala IE J, Paraskevaidi M, Mitra A, Martin‐Hirsch PPL, Arbyn M, Bennett P, Paraskevaidis E. Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease. Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No.: CD012847. DOI: 10.1002/14651858.CD012847
20 The patient with previous borderline ovarian tumor
Arri Coomarasamy1, Kavita Singh2, and Jennifer Tamblyn1
1 University of Birmingham and Birmingham Women’s Hospital, Birmingham, UK
2 Pan-Birmingham Women’s Gynaecological Cancer Centre, City Hospital, Birmingham, UK
Case History: A 35‐year‐old woman was found to have a 7× 6 ×5 cm left‐sided complex ovarian cyst during an IVF workup. She had a laparoscopic left‐sided salpingo‐oophorectomy on the recommendation of a gynecologic oncology multidisciplinary team. The histology was reported as borderline ovarian tumor. Six months following the surgery, she re‐presented to the IVF unit requesting fertility treatment.
Background
Borderline ovarian tumors (BOTs) are a subgroup of epithelial ovarian tumors with low malignancy potential. Histologically, they are characterized by cellular proliferation and nuclear atypia, but in the absence of identifiable stromal invasions [1]. They account for 10–20% of all ovarian tumors, and are particularly common in women of reproductive age, with approximately one‐third of all BOTs occurring in women under the age of 40 years [1].
In women who have completed childbearing, the optimal treatment for BOT is considered to be hysterectomy, bilateral salpingo‐oophorectomy, omentectomy and multiple peritoneal biopsies [2]. However, as they often occur in women of reproductive age, and generally have excellent survival prognosis, fertility‐preserving surgery is usually offered to women suspected to have BOTs. Fertility preservation involves preservation of at least part of one ovary, and the uterus. Laparoscopy is often the standard approach for surgery. Although the rate of recurrence is higher following conservative surgery, this does not result in a higher mortality rate [3].
BOTs are bilateral in 25–50% of cases. In such women, the fertility‐preserving surgical option is either bilateral cystectomies or unilateral oophorectomy plus contralateral cystectomy [4]. In women
